CIRRHOSIS

CIRRHOSISfinal and irreversible form of alcoholic liver

diseaseThere is development of fibrosis which replaces

hepatocytes that have permanently lost their function.

architectural distortion formation of regenerative nodules resulting in decreased hepatocellular mass, function and alteration of blood flow.

(Most common)

SIGNS AND SYMPTOMS

vague right upper quadrant pain

fever, anorexianausea and vomitingmalaise, weight lossedemaascitesupper GI hemorrhagespider angiomascleral icterusgynecomastia in men

hepatomegalyjaundicepalmar erythema

Diagnostic proceduresUltrasoundCT Scan

Hematologic abnormalities

 Anemia Hemolysis

Hepatic encephalopathyPortal hypertension Gastroesophageal varices Splenomegaly, hypersplenism AscitesMalnutritionCoagulopathyHepatorenal syndromeHepatopulmonary

syndromeBone disease

Complications of Cirrhosis

•Hepatic Encephalopathy-altered level of consciousness due to accumulation of toxic metabolites, especially ammonia

Tx:-Lactulose - used in treatment of encephalopathy brought about by hyperammonemia. It limits the proliferation of ammonia-forming gut organisms and increase the clearance of protein load in the gut, metabolized in the colon and is not absorbed-Non-absorbable antibiotics- limits growth of intestinal bacteria

•Portal hypertension

-use of antihypertensive drugs- Diuretics are given to reduce fluid retention in patients with ascites

Abstinence is the cornerstone of therapy for patients with alcoholic liver disease.

Nutritional TherapyMalnutrition is often a problem for people with cirrhosis.

In patients with severe malnutrition, inadequate caloric intake was associated with 51% mortality compared with 19% mortality in patients who received adequate oral nutrition

Causes of malnutrition in patients with cirrhosis is multifactorial and includes decreased intake, altered metabolism and increased nutrient losses.

Avoid foods that are high in sodium, such as canned soups, many canned vegetables, processed meats and cheeses, condiments, and many snack foods.

Avoid foods that may cause foodborne illnesses such as:

-unpasteurized milk, cheese, yogurt, and all other milk products

-raw or undercooked meat, poultry, fish, seafood and raw tofu

-raw or undercooked eggs-unwashed fresh fruits and vegetables-all raw vegetable sprouts (radish, broccoli, mung

bean)

Carbohydrates (57%)

 food should be generally high in complex carbohydrates (breads, cereals, grains, legumes, dried beans and peas, pasta, rice).

Diet should include at least 21g of fiber (avoid excess fiber to optimize gastric emptying)

Protein (19%)

approximately 40 grams of protein a daytoo much protein can raise ammonia levels and

trigger hepatic encephalopathy. It is recommended to eat vegetable protein such as soy, instead of animal protein.

Fats (24%)

low fat diet is indicated for patients with cirrhosis

A vegetarian diet may significantly improve symptoms of hepatic encephalopathy.  

Plant–based diets have more dietary fiber, which may reduce hepatic encephalopathy by removing toxic ammonia from the body.

Vegetable protein sources are also higher in arginine that decreases blood ammonia levels; are lower in methionine and tryptophan which increases the risk of hepatic encephalopathy.

Sodium (2000mg)

Less sodium intake is recommended to prevent water retention.

Foods with the highest salt content should be avoided such as canned meats, soups, cheese, condiments, crackers and junk foods.

Instead of adding salt, use herbs to add flavor to the food.

A diet high in vitamin A, antioxidants, and B–vitamins

 Cirrhotic patients have significant reductions in antioxidants in their blood.

The best way to supplement the body with antioxidants is to eat plenty of fruits, vegetables, and whole grains.

They are likely to benefit from a daily multivitamins that meets 100 percent of the dietary allowance for all vitamins and minerals.

Probiotic supplementation may improve hepatic encephalopathy.  

-by decreasing the blood concentrations of toxic ammonia and decrease the risk of life–threatening infections.

Meal planning:

eat small amounts of food more oftenchoose foods that are high in calories (such as

whole milk and canned fruit packed with heavy syrup).

Try fresh or dried herbs, spices, oils, vinegar, or juices to add flavor to the food.

Look for no-sodium or low-sodium versions of foods

Parenteral Nutrition

Parenteral nutrition is associated with increased infectious

and metabolic complications compared to enteral feeding.

Parenteral nutrition should be reserved only for those patients who cannot receive enteral nutrients (ileus, small bowel obstruction)